Modifier 25: to use or not to use
Practices struggle with whether or not a separate office visit on the day of a procedure is supported. This article and the accompanying updated CodingIntel's audit tool can help.
CPT guidance
The CPT® definition of modifier 25 is: “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT® code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.”
What is beyond the usual preoperative and postoperative care? How is a significant and separately identifiable service defined?
The AMA publication “Principles of CPT Coding” has a flow chart that indicates that typical pre-procedure and post-procedure work are part of the payment for the procedure and do not justify a separate E/M service. In March 2023, the AMA listed the specific activities and cognitive work that are part of the pre- and post-procedure work and don't constitute a separate EM service. In addition to the list, the AMA document has clinical examples of when an office visit on the same day as a procedure is supported.
CMS and NCCI
In chapter 1 of the NCCI manual , a minor surgical procedure is defined as one that has 0 or 10 global days. NCCI states that the decision to perform a minor surgical procedure is included in the payment for the minor procedure and should not be reported with a separate E/M service. The next sentence says that a significant and separately identifiable E/M service may be reported on the day of a minor surgical procedure. The definition of “significant and separately identifiable” isn’t really defined.
CMS has an example in the Medicare Claims Processing Manual that is useful. “For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.” 100-04, Ch. 12 40.1.C Applying the CPT list of included activities, assessing a patient for neurologic deficits would not be considered typical pre-procedure work, while confirming allergy and immunization status would be considered typical pre-procedure work.
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Do we have to agree to disagree?
Practices and payers routinely disagree about whether documentation supports a separate E/M. Practitioners and auditors disagree. Frankly, coders can review the same encounter and disagree about whether to add a separate E/M service. The new AMA guidance from last year helps by specifically listing the activities and cognitive work that are included in the typical pre- and post-procedure work related to the minor procedure. The new guidelines will certainly reduce disagreement.
Diagnosis coding
In Appendix A of the CPT code book it states that the E/M service can be prompted by the same symptom or condition for which the procedure is performed. “As such, different diagnoses are not required for reporting of the E/M service on the same day.” Of course, revenue cycle professionals often report that payers deny the E/M service more frequently if the same diagnosis is used on the procedure and the visit. Neither CMS nor CPT requires a different diagnosis, however.
Audit tool
Auditing needs to be both valid and reliable. Validity is a measure of accuracy, and reliability is a measure of reproducibility. If using an audit tool, the questions on the tool should assess the issue accurately. And, if an auditor uses the same tool over and over again or different auditors use the same tool, the results should be consistent. At CodingIntel, we've updated our modifier 25 audit tool to reflect the AMA changes. Honestly, whether we are in agreement with the AMA or not, the list of activities and cognitive work will help all of us to be more consistent when we assess encounters with both an E/M and a minor procedure. In some instances, it may give us support for appealing a denied visit. In other instances, it may give the payer support in denying a visit.
The job of the audit tool is not to maximize or minimize reimbursement. It is to accurately and consistently allow an auditor or coder to come up with accurate results.